Культурно-исторический подход как инструмент исследования травмы среди беженцев в Европе

Introduction

Europe is living through a refugee crisis of historic proportions which has now become one of the continent’s defining challenges of the early 21st century. Not least among the difficulties are the public health challenges of the multiple traumas faced by this population which constitute severe threats to human, social, cultural, and community development. The psychological impact of atrocities endured by refugees^[1] populations is clear, with the literature reporting significantly high prevalence rates of post-traumatic stress disorder (PTSD) among this population [11; 23; 25; 43; 52; 61; 68]. Despite the high prevalence of PTSD noted among refugee populations, there have been significant concerns raised in the literature over the relevance and cross-cultural validity of this psychiatric diagnosis: the work of anthropologists [71], psychiatrists [53] and sociologists [14], among others, have long criticised PTSD as a heavily politicized and westernised social construct.

A reductionist vision of trauma inherent in a classical psychiatric diagnosis risks individualizing and medical- izing the issue by focusing attention on therapeutic outcomes rather than a political response to the structural issues that led to trauma in the first place [36]. It risks rendering us blind to other ongoing aspects of interpersonal, political and social violence on a more global scale, including significant post migration factors which may be deemed equally traumatic by refugees, including current social, political and economic realities and lived daily experiences in host countries [31; 44; 45]. These criticisms of PTSD therefore highlight the need for a more nuanced, contextualised and ‘decolonized’ understanding of trauma as being significantly determined by larger cultural systems and historic contexts [7; 10; 23; 33; 34; 35; 41; 58; 70; 73; 74].

Given the numerous criticisms surrounding the use of PTSD among refugee populations, we argue that cultural-historical psychology allows for a unique perspective in which to examine trauma among this population. Notably, we aim to bring a critical regard towards ‘psychiatrisation’ and the isolation of the psychic from the sociocultural context [17; 18], arguing instead for a non-reductionist ontological vision of human nature and development as being rooted in material social practices [51], and wherein subjective human experience is inevitably connected to external reality [60; 62]. This framework therefore advocates for a move away from the essentialist and context-independent notions of PTSD toward viewing experiences of trauma as being embedded within sociocultural contexts and intrinsically interwoven with them [50]. As such, it is “based on the notion that social and psychological phenomena are processes that exist in the realm of relations and inter- actions—that is, as embedded, situated, distributed, and co-constructed within contexts while also being intrinsically interwoven into these contexts” (p.7) [50]. We draw on a Vygotskian perspective of culture noted by Dauite and Lucic [9] wherein ‘culture’ is not presumed to exist in values or beliefs of ethnicity, gender, or other categories but in the creation of meaning through symbolic thought in situations on the ground. As the primary location of development, social interaction, according to this theory, is not only an influence but the basis for human processes of knowing (p. 616).

Vygotsky’s strong influence on culture and the social origins of psychological processes is particularly relevant to our increasingly diverse multicultural societies, and in particular giving the influx of refugees into Europe [8]. As noted by Roth and Lee [40], the analytic challenges raised by Vygotsky regarding the “atomistic and functional modes of analysis ... [that] treated psychic processes in isolation” (p.1, as cited by Roth and Lee, 2007) remain unresolved. Indeed, one of the principal contributions of the Vygotsky-Luria project is the establishment of a “new psychology” — a ‘decolonized’ way of understanding human thought and activity which takes into consideration the inseparable unity of mind, brain and culture in concrete socio-historical settings [57]. From its very beginning, this collaborative project rejects (a) any dualism between physiological and mental phenomena and (b) any dichotomy of the individual and the society of which the individual is a constitutive part. Vy­gotsky’s approach thus sees each psychological function as being comprehensible only when we see it as a part of an interrelated structure which ontogenetically co­evolves within a certain sociocultural environment [26]. Indeed, as Smagorinsky [46] reminds us, Vygotsky took a revolutionary approach to the education of the blind, the deaf, the maimed, the cognitively different, and others falling outside the textbook and diagnostic norm by instead focusing on the settings of human development and their role in supporting and accommodating those who fall outside the diagnostic normal range.

Therefore, consistent with major Vygotskian principles of interactive individual—societal development via the creation of meaning in everyday activities [9], this paper presents the results of a qualitative investigation into the subjective experiences of trauma among refugees. The study incorporates various units of analyses including historicity and context as well as social and material environments in an attempt to go beyond an ‘atomistic’ or individualised framing of psychological difficulties — a particularly relevant consideration for understanding trauma among refugees in light of the multiple and arguably ongoing environmental stressors with which they are faced as they negotiate material ecologies which both enable and constrain their human activity. In particular, our study aims to address the following questions:

•    How is the experience of trauma among refugees “historically rooted, socially constructed and culturally shaped” (Veresov, 2017)^[2]?

•    How do the asylum seekers diagnosed with PTSD arrange, organize, direct and regulate their life activities to ‘not only answer to past or present conditions, but also envisions future ones, contributing to their creation as they evolve in the fabric of social life?’ [51].

Methods

We present a case study from a 12-month research intervention with NGOs addressing the refugee crisis in Athens, Greece — a project which included 125 qualitative, in-depth interviews among staff, cultural mediators, community leaders as well as individual refugees diagnosed with PTSD. It also included 3 months of participant observation within a clinic for refugee victims of torture (including facilitating workshops for staff members and beneficiaries and attending morning team meetings, etc.) — an important condition for creating the social space within which the research could be realized [18]. Ten individual refugees diagnosed with PTSD were followed over the period of a year, with an average of five in-depth interviews being conducted with each participant. Individual participants interviewed were all victims of torture in their respective countries of origin who subsequently sought psychological and medical attention from NGO clinics in Athens, Greece. The 20 refugee community leaders were interviewed in order to broaden our exploration into the multiple traumas to which refugee communities are exposed, and some subjective understandings of ‘PTSD’ as a diagnosis among this population [42]. By interviewing both individuals as well as community leaders, we attempt to gain a deeper understanding of life trajectories, dynamic processes, interactions and the continual development and change in psychological symptoms; an exploration which equally incorporates a focus on the ever-changing cultural and social systems which determine the various forms of individual subjective experience of psychological difficulties [38].

The design draws on a cultural-historical framework which focuses on the intersubjective, mediational space between the individual and culture-society-interaction: an approach to understanding human mental functioning and action that focuses on how culture, history and social interactions shape individual consciousness, with a focus on the various levels in which to make sense of human mental functioning: phylogeny (the history of the species), the cultural history of the social group, on­togenesis (the personal history of the individual), and micro-genesis (a microhistory of specific events in the life of the individual, including traumatic events).

Through the analytical lens of dialogism

Telling a story of trauma or reliving it necessarily occurs in a larger dialogical matrix of narrative and social praxis [22]. Vygotsky came to postulate that psychological matters should be studied “in the process of change,” in its “development of all its phases and changes” (p. 64—65) [64]. Indeed, studying psychological processes in their development remains a key component of Vygotskian tradition [26; 63; 46; 59; 29]. Vygotsky [65] emphasised that

We wish to obtain a clear idea of the essence of individual and social psychology as two aspects of a single science, and of their historical fate, not through abstract considerations, but by means of an analysis of scientific reality (p. 237).

A dialogical analysis of interviews over the course of a year thus allows us to track the dynamic development of individual’s subjective experiences of trauma within the context of their daily-lived realities. Such a dialogi­cal approach presupposes human beings inhabit shared forms of life, that meaning is continually negotiated within the social sphere, and that ‘cultural products, like language and other symbolic systems, mediate thought and place their stamp on our representations of reality’ (p. 3) [6]. Within this perspective, subjective experiences of trauma cannot merely be internally homogenous but involve multiple voices, texts, interests and traditions embodied in each individuals own varied histories and in the artefacts and norms of the system — a source of trouble and of innovation [2; 3].

This dialogical analysis explores how an individual’s experience of trauma necessarily is influenced by and reflected through language and culture — acknowledging that current concepts of mental health, notably a diagnosis of PTSD, are to some extent socially constructed objects produced within a specific historical period [38]. The perception of trauma then is mediated through collective memory and the inter-generationally transmitted historic experiences, myths or stories from the past shaping worldviews [13]. Here, elements of temporality are considered, as well as the continual interaction of the person with their environment in a given social and historical context.

Results

The case of Mr B

Mr B is a thirty-four-year-old Sudanese refugee victim of torture, referred to the clinic with a diagnosis of PTSD and a myriad of medical complications needing surgical intervention and ongoing physiotherapy. He begins the first interview by introducing himself:

My father is X. My grandfather is XX. My father’s grandfather XXX. My name I use here is to greet according to family names. My name is XXX but here it has been changed to XXXX [...] I was born in Darfur not north, south of Darfur state. That is a small village [...] At that time, you know the Darfur case, the Darfur case that is the goal is not allowing all the Sudanese to come suddenly to Khartoum. That is difficult. A lot of times happening many things or more things. My history really is long.

From the moment of introduction, he immediately places himself within a long and complex history dating back to his great great-grandfather. Before stating his own name, the name of his ancestors are given; the entire family line is introduced. Even his own name reflects this rich family history, an integral part of who he is. He relates “my really long history” not only to the family but to the political history of his country, dating back to a time before he himself was born. The complex and troubled history of his country over decades continues to be a part of him, sitting in a room in Athens, Greece in 2017.

He continues the interview by detailing how he was arrested and detained for six months as a result of his political activism. He was tortured, and forced to live underground without seeing sunlight. After managing to escape:

Many things happened after. I decided to myself, or I say to myself what can I do to my futures. A, I have no future. A, I have no freedom. A, I have no education. Nothing. What can I do? I have many relations. I have many friends. I talk with them.

It was through his social connections that he was able to escape and make his way to Europe. Plans for his future were elaborated upon by talking with his “many friends” — the dialogues within this social interaction serving as a resource which allowed him to envisage and create future conditions [51]. This continues to be evident in his recounting of his escape from Sudan into Libya, where interactions with others allowed him to construct plans for the future:

Libya really situation is really difficult for me. I don’t know other people. They have no way I can know. I can do some things to myself. After what can I do. I listen some people say, the peoples go to other place, go to Egypt. After to Egypt take the ship, come to Turkish, Greece, Greece to Italy, Italy to somewhere. The people talk, just this information. I have no idea about these things. Just I listened.

Finding himself removed from his family, community and a familiar sociocultural environment, a new space is opened wherein both he and the asylum seekers around him share information in a collective attempt to negotiate the migration journey and make sense of their experiences. Within the history of the cultural-historical approach, we can understand this process by drawing on Vygotsky’s concept of sense which he defines as “ the aggregate of all the psychological facts that arise in our consciousness as a result of the world. Sense is a dynamic, fluid, and complex formation which has several zones that vary in their stability” (p. 276) [64]. Mr B describes attempting to understand and master his new environment: it is a dynamic and fluid process based on the constantly changing environment, a process inevitably socially and culturally situated.

He continues to describe his journey

I make it to Athens, go to Greece, what can I say. I succeed. I get the paper but really the Greek situation is very difficult. There are many friends from that time who are staying together in X. Some people have good chance, maybe two weeks, or three weeks go to Italy. After Italy people go to France, after go to Holland, go to Sweden and people go to Germany, people go to England, different countries ... these are people who succeed. I am here too. It is difficult here. No schooling. No integration. No, the refugee system is difficult for me, for us.

He refers to these current difficulties as being equally traumatic for him, a source of suffering having just a significant impact on his mental health as the torture he experienced in his country of origin. All references to the stress encountered in his daily life in Europe are represented collectively and communally, the situation is not only difficult “for me,” but “for us.” He then continues by describing the fact that he sees very little future for himself in this current situation, far from family back home. Disaffiliation, de-cul- turation and de-linking both in terms of family and social ties similarly affect the internal capacity to make links between different events and moments in life. From within a dialogical paradigm, this lack of connection to a possible future is intrinsically linked to a severe disruption of the relational processes by which meaning is dialogically created. It is difficult for Mr B to make sense of his past, present and future without a dialogical other present : for the transformation of traumatic memories into semiotic forms which connects it through language to its rightful place in time, the elaboration needs to be socially situated and ‘in- tersubjectively acknowledged’ (p. 485) [73]. Instead, Mr B describes feeling isolated and alone.

Really, the body has contacts with, you know, with mind and body has contacts to other side. Which other side? This is my family’s pain. I feel the pain of my families. You know, it’s feeling my pain [,..]_here I am alone. Yes I have friends, you know, all around me I have friends but these friends, eh, yes . but not something else you know have, can do something to me, to my pains or to my problems.to my knee or something like this. This one. Really, every day or every times, I am thinking to my families. You know, my family. My sisters, my brothers, and my mother. Yeah. This is in my place [.] really I feel the pain of those people.

He explains that the pain that he is currently feeling is not merely his own, but “the pain of my families.” This contradicts the inherently individual narrative of PTSD. This more collectivist representation of trauma has similarly been noted researchers and clinicians working within collectivist communities wherein individuals rely more heavily on larger family systems; here, mental health is typically seen to be more linked to a broader so­cio-cultural context [1; 5; 13; 30; 55]. As Tang [55] notes : ‘cultures differ regarding their dominant ideas about the ontology of self as well as relationship between self and others, between self and the universe, and between life and death.’(p. 129). Tankink and Richers [56] give the example of South-Sudanese research participants who did not experience themselves so much as an individual in the Western sense of the term, but more as having a ‘family self’ based on relational models where experiences are considered more within the intersubjec- tive realm of the group rather than on an individual, in­trapsychic level.

Equally noteworthy is the fact that he refers not only to the historical pain experienced by generations of family members exposed to conflict in Sudan, of which he himself is also a victim, but also the ongoing conflict in his country to which his family members continue to be exposed. The suffering in Sudan, in “my place” is felt in Greece. Trauma does not stop at the border. Paradoxically, this collective suffering seems to be exaggerated by his physical separation from the family: what is difficult for him is to experience this suffering — affecting his entire family — but to experience it “alone,” among people in Athens who may not be able to relate or understand. In this context of migration, itself characterized by disruptions in connection to ‘home’ (and all the social, cultural and linguistic connections that this implies) — the physical, social and political isolation so typically experienced by asylum seekers upon arrival to host countries and often imposed by the state through legal requirements, serves only to feed monstrous feelings of invisibility and disconnectedness [4]. He continues by poignantly stating that “the more I stay here, really, I feel the pain.”

Analysed through a Vygotskian framework which rejects (a) any dualism between physiological and mental phenomena and (b) any dichotomy of the individual and the society of which the individual is a constitutive part, what is highlighted is Mr B’s representation of trauma: the physical pain affecting his knee is linked to his psychological suffering, his own psychological suffering intrinsically connected to the suffering of his family which in itself is both physical and psychological, both current and historic. In reflecting on this subjective experience of trauma, Mr B summarizes his mental state by saying “my mind is not like before really.”

When interviewed a few months later, in September 2016, the team noted a remarked improvement in his post- traumatic symptoms. They observed that he had more energy to become involved in various projects and that his mood had become more positive. He himself stated:

You must try, you do something like masters [..] When I was travelling, you talk to different cultures, you talk to different peoples. We have many societies. After this you can get a job easily. You have many degrees or you have many certificates, or you have good mentalities, easily you can get a job or something like this. Actually try to your life, you build your life.

This is yet another example of the way in which his orientation towards a future, towards building a life, is inevitably dialogic in nature. It is through exposure to different cultures, talking to different people, that he is able to improve both his current material reality (“get a job easy”) and his mental health (“mentalities”). Indeed, within this subjective representation, rebuilding one’s life following a trauma is a) connected to others within the sociocultural environment and b) the current environmental reality, including improved living conditions and being able to work and contribute as a productive member of society. This process of “building a life” is is a lived social reality, continually and creatively co-constructed in micro-interactions and inevitably socially, politically, and historically contextualized. It is inter- subjective [3; 27; 32].

Interestingly, he relates this improvement to relationships that he has started being able to construct in Europe with various people: neighbors, friends, the Sudanese community of Athens, and the medical team of the clinic:

I can talk with doctors. I can talk my friends and relatives and you know the people struggling, society, or our communities

One striking and ironic exception to this is the one relationship which he doesn’t believe to have had a positive effect on his mental health: that with his psychologist. Culturally-informed differences in representations of trauma were apparent, whereby Mr B felt his psychological suffering to be deeply culturally and historically connected, as opposed to his psychologist who felt it to be internal, individual, and related to a fixed incident in the past:

Then I start to talk, saying, “Okay. You have to listen, you have to record in the mind” you know — this is the psychologist. Just record, make record. Okay tell me, again and again. After really, I suffer to talk. I don’t like, you know, thinking about something that’s happening before. Really, you know, I just want to forget it. I want to put it in the rubbish place. After, really, I start to talk with this psychologist, after I go back to my home, really I feel the pain, I feel the pain. Why? Something is happening before seven years or six years. I don’t like to forget again these things, but now it’s renew again. Why this person is asking these questions? Really, these things, why I am not like, I don’t like to go to psychologist [...] The better thing, really, is if something is happening bad — forget it! After you can remember, not change somethings, not change some things to your future, something has past. Not give you some defence or some power, but a new, a new being. I believe all things you can do good things, you know, to other people or to yourself, for following your future. Really, these bad things, these I’ll not forget to these things

Many implicit differences emerge in his speech between his own culturally-determined understanding of trauma, and that of the psychologist. He believes that the past is something to “forget,” not talk about. He believes that he needs to orientate himself towards a future, not the past. He believes he should be focused on something “new,” not something “rubbish.” He wants to connect outwards, “to other people,” not inwards. As a result, when he’s asked by the psychologist to talk about the past, it brings him pain:

the psychologist started to ask me more questions, after I start to answer, really I feel the pain. Body pains, to heart pain. Really I am suffering. Eh, I . never I can forget these things happening to me. I see that there is a lot of peoples suffering. You know, this one. Suddenly, after I remind these things, really I feel the pain more. Never I can, for example, in the evening, never I can sleep. During all this time, you know, I remind this bad things, I forget before something is happening. Six years, or five or seven years. This is not really can support to me, or give me some power.

Implicit in the exchange he describes is an unequal distribution of power related to western knowledge: it is the victim of torture diagnosed with PTSD who needs to understand trauma from the perspective of a westernised, medical model of distress. This “internationalisation and professionalization of adversity” (p. 493) [37] enforcing “the asymmetry of the therapeutic relationship” (p. 143) [66] has been criticised in the literature as a form of “cultural imperialism” [48] serving to reinforce existing imbalances of power between Western ‘expert’ and ‘victim-patient’ [53; 67]. Mr B continues by explaining that his psychological suffering is not exclusively linked to his experiences of torture, but to a myriad of factors within his sociocultural environment:

Really, I have a long time, I didn’t see my mother or to my family or to my relative, you know [.] I have a lot of friends, the same generation we are growing up together, those people now have families, have children, have many things. But until now I have nothing.

What he describes as being traumatic is being torn away from his social environment, he no longer sees himself within cultural-historical context, as one in a long line of generations of family members and someone actively engaged in his community:

Before I have many activities. The people in our village, in our towns, in our area, I have many activities [.] Now our activities are not like before. You know? Our activity is not like before.

The switch from “my” activities to “our” activities is significant, one more example of the way in which trauma may be collectively or communally represented, not necessarily restricted to the level of the individual as is implicit in a PTSD diagnosis.

In January 2017, four months after our last interview, Mr B describes feeling even stronger both mentally and physically:

After slowly, slowly this leg is coming strong. Really I appreciate all to my friend and to my relatives, and I am happy really. As many people support to me, and they support to me — and really I have outside of Greece many friend send me many messages. Really I want to stay at one place. I want to open new chapter. I want to do something, yes, really.

The improvement is attributed to two factors: a) a physical improvement in his leg, thanks to surgery and ongoing physiotherapy and b) a feeling of social connection. The physical rehabilitation resulted in him receiving social support (“messages from friends”), which in turn resulted in an improvement in his mental health and a new, more positive orientation towards the future. Reflecting on this change, he states:

Yes, really something has changed. I want to say I’m proud. I’m not like before. How many times I’m thinking when I was here you see my knee, think after two weeks or three weeks maximum it give me more power, I can walk better. Yes, this one, and before some dreams and these things not like before, now it’s come better. Yes, I have no more bad dreams. This is a bad dreams and sometimes frustrated and this, no. These things I think I close these chapters.

The pride he describes is related to having a new social position and outlook for the future, to physical improvements in his knee. As a result, there has been a reduction in his PTSD symptoms, he no longer experiences nightmares. The experiences of trauma are inherently connected to his material reality. This improvement continued over the following few months. When interviewed in August of 2017, his physiotherapist reflected on this process of change:

If you have seen him in the beginning, he was a human rag. First of all, he wouldn’t take care at all of himself, dirty nails. not dirty, dirty but uncared, very often talking about killing himself based on the idea that, «Is this a life?» «How can I live like that? I will never walk again,» every negative thought you can imagine. He is another person. He steps on his feet literally and metaphorically [...] when he believes that the dream is still on then she can go, he’s okay. Whenever something. I don’t think, it’s only the pain or it’s also that he feels that this goes on and on. And he cannot go on to realize his plans.

The physical pain is connected to the psychological, the psychological to the social, the social to his plans for the future. As neatly and rather aptly summarized by Mr B himself:

You know, my future has contact with my leg

By following Mr B’s subjective experiences of trauma over the course of the year, what becomes strikingly apparent is the connection of these experiences to his lived social and material reality. His physical health, his ability to work or not, his connection to others. all have an impact on the way in which he attempts to build a life for himself and how he orientates himself towards the future. Furthermore, his understanding of trauma is not static, but dynamic, and deeply connected to the cultural and historical context in which he finds himself.

Conclusion

The case of Mr B illustrates the heterogeneous, fluid and dynamic nature of individual subjectivities and the multitude of socio-culturally determined discourses which may be drawn upon to make sense of traumatic experiences [15; 47]. Not only do reactions to trauma differ according to cultural norms, but the very making sense of what is or what is not traumatic may similarly be informed by socio-cultural context [10; 73; 74]. This brings “profoundly into question not only the universality of knowledge from one domain to another, but the universal translatability of knowledge from one culture to another” (p. 2) [6]. It serves to illustrate the possible risks of health professionals, particularly those within a humanitarian context working with refugees, imposing a western representation of trauma that reduces it to the isolated and static level of the individual. According to Goulart and Gonzalez Rey [18], this western logic “conceives of ‘mental disorder’ as a deviation from an idealized general norm and treats it as an individual phenomenon, to the detriment of its subjective, social, and cultural dimensions. Consequently, together with the users’ emotional fragility and lack of social bonds, an institutional configuration that associates mental disorder with social exclusion arises and crystallizes. Thereby, this situation generates an institutional vacuum that precludes the individual from developing a sense of citizenship, leaving him/her in a situation of marked vulnerability.” (p. 7)

By reducing the individual to a diagnostic disorder such as PTSD, one risk is to reinforce a focus on vulnerability, on damage, on social exclusion. Furthermore, presenting a western-orientated representation of trauma risks isolating those with different culturally based understandings of their subjective experiences. As noted by Williams [69], being aware of these risks has implications for humanitarian interventions among refugee populations: “practitioners, in particular, need to understand the dynamic and multidimensional nature of culture, the impact of power dynamics in their practice, and the steps that must be taken to make evidence-based practices culturally appropriate and responsive” (p. 57). The results of our study show that professionals are, to a more or less extent, aware of these dynamics. This echoes the experiences of clinicians working with refugee populations elsewhere, many of whom have articulated the need to consider the impact of the cultural and political environment on the mental health of this population [12; 19]. However, in this article we aim to add to the scientific literature conceptualising these dynamics through a uniquely cultural-historical exploration.

We aim to highlight the important value cultural- historical psychology may bring to this field by enriching understandings of “historical trauma” [16] or collective, cultural, and identity-related trauma among refugee populations, with its emphasis on the social location of human subjects and a recognition that trauma responses may carry a sense of group burden and collective suffering beyond symptomatic individuals. Furthermore, it brings a critical focus to bear on the political and social environment in which trauma occurs. From within this perspective, what is highlighted are the ever-changing cultural and social systems which are in continual interaction with the various forms of an individual subjective experience of mental illness. The individuals interviewed are seen as being deeply embedded in complex and dynamic activity systems in which resources are exchanged — wherein individuals are both capable of negotiating and influencing this system as well as being influenced themselves by the system. Understanding that people always contribute to social practices, rather than merely participate in or sustain them, places activities that allow individuals to purposefully transform the world at the core of human development, as an instrument of social change [51]. As refugees continue to migrate to Europe, many of them exposed to a myriad of various traumas, future research is imperative in order to continue to explore the ways in which the current political and social conditions in host countries may affect the mental health of these individuals. Cultural-historical psychology allows for this urgent and critical reconsideration of trauma as not only a personal medical condition, but also as the product of the interplay of changing social, historical, material, economical, political and subjective dimensions, in populations fighting to construct their new lives in Europe.